Complaint Investigation Report

392701183-5-20-2026-27-AS-LKIG-DVDMTL-20260625095343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO SOUTH ASC , 9835 GOETHE ROAD, SUITE 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

11/24/2025 and conducted by Evaluator Noel Wolf Petersen

COMPLAINT CONTROL NUMBER: 27-AS-20251124143630

Staff did not prevent a client from sustaining a fracture while in care

~ Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to deliver findings of a department report investigating a complaint with the above allegations. LPA met with substitute administrator Emilia Baguinon, designated representative of Starbloom Care Home via LIC 308 to explain the purpose of the visit.

~ The report finds insufficient evidence to support a lack of care resulted in a resident sustaining a fracture. Resident was unable to provide a statement as to how the injury occured. File review records indicate medical conditions which may or maynot have contributed to the injury. Interviews were conducted with facility staff. There was no indication of witnessed or unwitnessed falls. It was unclear how resident sustained the fracture. Due to the lack of evidence in establishing how the resident sustained this injury, this allegation is Unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

~ A copy of the report was read and given to the substitue administrator. Appeal rights provided. Exit interview conducted.